Healthcare Provider Details

I. General information

NPI: 1073264826
Provider Name (Legal Business Name): LIBERTY CARE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8005 N POINT BLVD STE H
WINSTON SALEM NC
27106-3267
US

IV. Provider business mailing address

5906 GREEN MEADOW DR
GREENSBORO NC
27410-2520
US

V. Phone/Fax

Practice location:
  • Phone: 336-759-7207
  • Fax:
Mailing address:
  • Phone: 336-337-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: RYAN CABELL GRAGG
Title or Position: MEMBER
Credential:
Phone: 336-337-8964